Leung, GM

Hong Kong Medical Journal

HKU Scholars Hub

Title The challenge of chronic conditions in Hong Kong.Author(s) Leung, GMCitation Hong Kong Medical Journal, 2002, v. 8 n. 5, p. 376-378Issued Date 2002URL http://hdl.handle.net/10722/53524Rights Hong Kong Medical Journal. Copyright © Hong Kong MedicalAssociation.376      Hong Kong Med J Vol 8 No 5 October 2002DOCTORS AND SOCIETYThe challenge of chronic conditions in Hong KongThere has been a continuing epidemiological shift awayfrom acute diseases to more chronic illnesses in developedcountries since the 1960s. By 2020, the rank order of majordisease burden is projected to be dominated by chronic con-ditions (Table).1 Acute diseases affecting mainly childrenin developing countries are expected to decline significantlyas global immunisation reaches most countries.1 Therefore,chronic conditions are expected to become the main causeof morbidity and mortality worldwide, contributing twothirds of the illness burden with enormous implications forhealth resource allocation.1 The demographic transition toan ageing society, the implementation of rapidly advancingtechnologies, and the ever upward cost spiral of health caresystem financing will compound the already heavy economictoll of meeting the needs of chronically ill people.How can health care professionals contribute to meetthis enormous challenge? The Medical and Health ResearchNetwork of the University of Hong Kong convened a con-sensus meeting in December 2001 to develop an evidence-based framework for meeting this challenge. Panel membersrepresenting a wide spectrum of stakeholders—internationalagencies, local government, academic institutions, healthand welfare professionals, and patient groups— participatedin the meeting and contributed to the content of this essay.Needs assessment and the wider determinants ofhealthTo provide a valid basis for such difficult policy decisionsas meeting the challenge of chronic conditions, reliable andcomprehensive data on the population health status areneeded. A new approach to measuring health statusneeds to be implemented—one that quantifies not merelymortality rates but also the impact of premature death anddisability.2 The disability-adjusted life year is such ameasure. Disability-adjusted life years express years oflife lost to premature death and years lived with a disability.A ‘premature’ death is defined as one that occurs beforethe age to which the dying person could have expected tosurvive if he/she was a member of a standardised modelpopulation with a life expectancy equal to that of the world’slongest-surviving population, Japan. Disease burden is, ineffect, the gap between a population’s actual health statusand a reference status.1Table. Epidemiological transition of diseaseFive leading causes of death in Hong Kong Five leading causes of disability-adjusted life years worldwide11947 1999 1990 2020Pneumonia Malignant neoplasms Lower respiratory tract infections Ischaemic heart diseaseTuberculosis Heart diseases Diarrhoeal diseases Unipolar major depressionPerinatal/neonatal conditions Cerebrovascular disease Perinatal conditions Road traffic accidentsEnteritis and diarrhoea Pneumonia Unipolar major depression Cerebrovascular diseaseViolence Injury and poisoning Ischaemic heart disease Chronic obstructive  pulmonary diseaseRecommendation 1There is a need to invest in systematically expandingthe public health knowledge base that will provide theintelligence for continued health gains, through increasedfunding for research and development targeted at localpriorities.In addition to identifying the overall needs of peoplewith chronic diseases by studying the burden of illness,evidence points to the persistent inequalities in healthstatus found within populations. This is not a problem ofabsolute poverty per se and therefore restricted to develop-ing regions but one that affects disadvantaged populationsin all communities. Even among high-income populationssuch as Hong Kong, it has been shown that income inequal-ity produces adverse health effects for people falling on theleft side of the Bell curve.3 The best approach to the reduc-tion of inequalities is to focus on the underlying structuraldeterminants of social and economic deprivation.2,3Recommendation 2Minimising the excess burden of illness suffered by dis-advantaged people must be a priority. Efforts should befocused on interventions that will help lead whole commu-nities out of an inequitable distribution of resources.Intersectoral issues must be dealt with more effectively,particularly health risks that result from environmentalcauses in the broadest sense.Strategies for improving clinical outcomesChronic conditions present different challenges fromacute diseases, thus requiring a paradigm shift in diseasemanagement strategies. First, they are characterised bythe presence of numerous co-morbidities.4 Second, mosthealth care settings are poorly prepared to care for patientswith chronic disabilities.4 Third, frequent readmissions tohospital for exacerbations or complications, the need forlong-term follow-up and medication, and the involvementof multiple specialties are prominent features. Duplicationof investigations among disparate providers is common-place and there is often no coordinated care leading tosporadic and piecemeal services.5 Therefore, a more inte-grated approach to the management of chronic diseases isproposed.5 Essentially, all chronic disease managementHong Kong Med J Vol 8 No 5 October 2002      377programmes involve patient and family education, pro-motion of self-management, care process re-engineering,adoption of evidence-based protocols, and an informationtechnology infrastructure to support implementation andevaluation. This framework also includes improving carecoordination and controlling costs through integration ofservices across the entire spectrum of care.5,6Recommendation 3Health service delivery should move away from compart-mentalised systems focused on episodic care to an integratedmodel of chronic disease management.Moreover, primary care remains the best setting forthe treatment of patients with chronic illness. It has beendemonstrated that a strong primary care infrastructureproduces better clinical outcomes at lower costs.7 Whileconsistent evidence indicates that specialists are moreknowledgeable about the management of chronicconditions,8 primary care remains the first point of contactand the most efficient level of service. The challenge is toensure appropriate referrals to specialists without massivetranslocation of care. Shared-care arrangements hold realpromise and should be more intensively examined.9Recommendation 4An integrated and patient-centred model of care deliveryshould have primary care, and family medicine in particular,as its centrepiece. Shared-care arrangements should befurther studied and tested.Political economy in chronic disease managementGiven the enormous challenge of managing chronic diseases,the current level of politico-economic discussion aboutthis issue seems strangely circumscribed and muted. Ifhealth care professionals and the public are not engaged bythese problems, bureaucrats and legislators will not havethe political will or need to address them.Recent evidence from the World Health OrganizationCommission on Macroeconomics and Health encourages aradical rethink about the relationship between health,economics, and politics.10 The Commission maintains thatglobally, by 2020, additional health investments of US$66billion per year will generate at least US$360 billion perannum. Approximately half of this will be the result ofdirect economic benefits and the other half a consequenceof the indirect benefits from greater individual productivity.The commitment of increased resources may be a necessarycondition for intensifying health interventions, but theCommission recognises that such a commitment alone willnot be sufficient—political and administrative commitmentsare key co-requisites.It is vital to consider the audience that must be convincedby this evidence. The decisive audience is not the policy-makers but the public, especially the substantial number ofpeople with chronic diseases who stand to gain or lose themost from the politico-economic discourse of how best tostructure policies to deal with the burgeoning implicationsof chronic conditions. Patients should be empowered notonly to take personal responsibility for their illnesses but,more broadly, to take an active role in the political economyof how best to formulate macro-level policies.Recommendation 5Health care professionals, policymakers, and the publicshould be encouraged to actively participate in the politico-economic discussions on policy formulation relating tochronic disease management, supported by rigorousevidence.ConclusionsThe burden of chronic diseases is high and will increasefurther. The issues outlined constitute an agenda for HongKong. Some of the latest evidence has been presentedand a series of broad recommendations for helping thecommunity deal with the onus of chronic conditions havebeen laid out. How best to implement these measuresremains a puzzle, however, and requires the collectivewisdom and dedication of frontline workers. The tasks areset for us.AcknowledgementsThe consensus meeting was convened as a satellite sessionof and co-hosted by the Third International Symposium ofthe Asian and Pacific Parkinson’s Disease Association andthe Medical and Health Research Network, The Universityof Hong Kong. The Third International Symposium ofthe Asian and Pacific Parkinson’s Disease Association wassponsored by the Hong Kong Jockey Club Charities Trustand co-sponsored by the World Health Organization andthe Movement Disorder Society.Panel members (in alphabetical order)M Baker (European Parkinson Disease Association)C Chan (Faculty of Social Science, The University of HongKong)S Chan (Department of Nursing Studies, The University ofHong Kong)WS Chan (Department of Statistics and Actuarial Science,The University of Hong Kong)I Chi (Sau Po Centre on Ageing, The University of Hong Kong)D Fang (Health and Medical Development AdvisoryCommittee, Government of the Hong Kong Special Admin-istrative Region)SL Ho (Division of Neurology, University Department ofMedicine, The University of Hong Kong)A Janca (WHO Collaborating Centre, Australia)JS Kim (Department of Neurology, Yonsei UniversityCollege of Medicine, Seoul, Korea)PY Lam (Department of Health)CH Leong (Hong Kong Academy of Medicine)378      Hong Kong Med J Vol 8 No 5 October 2002* GM Leung (Department of Community Medicine, Medicaland Health Research Network, The University of Hong Kong)S Leung (Panel on Health Services, Legislative Council;Women’s Commission)WL Lo (Hong Kong Medical Association; Legislative Council)N Slewett (National Parkinson Foundation Inc., US)P Thompson (University Department of Medicine, Univer-sity of Adelaide, Royal Adelaide Hospital, Australia)R Yeung (Department of Community Medicine; Medical andHealth Research Network, The University of Hong Kong)YL Yu (Hong Kong Medical Journal)* (On behalf of the Panel)GM Leung, MD, MFPHMDepartment of Community Medicine and Medical andHealth Research NetworkFaculty of Medicine BuildingThe University of Hong Kong21 Sassoon RoadPokfulamHong KongReferences1. Murray CJL, Lopez AD, editors. The global burden of disease: a com-prehensive assessment of mortality and disability from diseases,injuries, and risk factors in 1990 and projected to 2020. Cambridge:Harvard University Press; 1996.2. The world health report 1999—making a difference. Geneva: WorldHealth Organisation; 1996.3. Wilkinson RG. Unhealthy societies: the afflictions of inequality.London: Routledge; 1996.4. Wagner EH. Meeting the needs of chronically ill people. BMJ 2001;323:945-6.5. Cheah J. Chronic disease management: a Singapore perspective. BMJ2001;323:990-3.6. Leung GM. Hospitals must become “focused factories”. BMJ 2000;320:942-3.7. Starfield B. Primary care: is it essential? Lancet 1994;344:1129-33.8. Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, andoutcomes of care for generalists and specialists. J Gen Intern Med1999;14:499-511.9. McGhee SM, Leung GM, Hedley AJ. Efficiency is dependent on thecontrol of supply. Hong Kong Med J 2001;7:169-73.10. Sachs JD on behalf of the Commission of Macroeconomics andHealth. Macroeconomics and health: investing in health for economicdevelopment. Geneva: World Health Organization; 2001.

The challenge of chronic conditions in Hong Kong.

http://hub.hku.hk/bitstream/10722/53524/2/80648.pdf

The challenge of chronic conditions in Hong Kong.

Abstract

Similar works

Full text

Available Versions

HKU Scholars Hub